Appropriate fluid replacement should be instituted promptly. Water and electrolyte losses occur secondary to polyuria caused by the osmotic diuresis produced by glycosuria, hyperventilation, vomiting, and diarrhea. Dry mucous membranes, poor skin turgor, and orthostatic hypotension in the older child are the most accurate clinical indications of dehydration. Virtually all patients with DKA are at least 5 to 10 percent dehydrated and require both maintenance and replacement fluid therapy. However, fluid resuscitation that is too aggressive can result in cerebral edema, the most lethal complication of DKA. For initial rehydration, 10 to 20 mL/kg/h of 0.9% NS solution should be given for the first 1 to 2 h of resuscitation to establish adequate vascular volume and improve tissue perfusion. If signs of shock are present, a 20 mL/kg bolus of 0.9% normal saline solution should be given and may need to be repeated if dehydration and shock are severe. However, for the majority of patients, the initial volume resuscitation of 10 to 20 mL/kg/h for the first 1 to 2 h is adequate to restore perfusion. Once this is accomplished, the remaining fluid deficit can be replaced over the next 24 to 48 h. If possible, the fluid deficit should be calculated by comparing the patient's weight on presentation with a recent, healthy weight. If such an estimate is not possible, it can be assumed that the fluid deficit is 10 percent of the body weight (100 mL/kg) in children in DKA unless the patient is in shock.
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